Pelvic pouch reconstruction after proctocolectomy

The ileoanal pouch procedure (IAPP) was the most remarkable breakthrough in the surgical therapy of ulcerative colitis (UC) and familial adenomatous p olyposis (FAP) in the last 20 years. The underlying disease is under contro l, the function preserved and the quality of life markedly improved. Altern ative procedures (terminal ileostomy, ileorectal anastomosis) are only indi cated in special cases. In the last 16 years we have operated on 662 patien ts (n = 493 UC; n = 169 FAP) with an ileoanal J-pouch, short rectal cuff, c omplete mucosectomy and hand-sewn anastomosis. Normally there is a good fun ction for UC and FAP patients after IAPP. Surgical experience, technical mo difications concerning the pouch design and the pouch-anal anastomosis, and a differentiated indication lead to a further improvement of these complex procedures with consecutive reduction of complications. Specific complicat ions concerned mainly the pouch-anal anastomosis (fistulas, abscesses, cons ecutive stenosis) and inflammation of the pouch mucosa (pouchitis). A multi variate analysis showed, that increasing experience of the specialized cent er is a significant factor reducing inflammatory problems at the anastomosi s. The cumulative incidence of pouchitis was 29%. In general there is no pr oblem in successful treatment. But patients with chronic pouchitis are a pr oblematic group (6.2%). Chronic pouchitis is difficult to treat. It is like ly that there exists an inflammation dysplasia carcinoma sequence for the i leal pouch mucosa, analogous to the colorectum. Recently we diagnosed the f irst case of a real ileum pouch carcinoma with associated epithelial dyspla sias following chronic pouchitis. Therefore patients with chronic pouchitis must be followed up by endoscopy and random biopsies in a surveillance pro gram. Patients with UC and FAP can gain the life quality of healthy control s, if postoperative complications can be avoided or treated successfully. F or the further development of the procedure and the individual longterm suc cess a qualified follow-up and therapy of complications is essential. Both can be carried out only by a specialized center.